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Modifier Coding Alert

Reader Question:

Consider Payer Preference When Making 52/53 Decision

Question: During an endoscopic retrograde cholangiopancreatography (ERCP) procedure, the surgeon made numerous failed attempts with the catheter tip and guide wire. According to the surgical notes, he then used the standard Hydratome. Over the course of an hour, however, the physician did not perform a single direct cannulation of either the common bile duct or pancreatic duct, nor did he insert the wire or contrast. How should I code this? 

Rhode Island Subscriber

Answer: You should report 43260 (Endoscopic retrograde cholangiopancreatography [ERCP]; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) with an appropriate modifier.

You have two modifiers that you could append to indicate an incomplete procedure: modifier 52 (Reduced services) or modifier 53 (Discontinued procedure).

Commercial payers that strictly follow CPT® coding principles will most likely require modifier 52. CPT® states that you should use this modifier when “under certain circumstances a service or the procedure is partially reduced or eliminated at the physician’s discretion.”

Because the CPT® definition for modifier 53 states that you should use it when extenuating circumstances threaten the patient’s well-being, you should reserve this modifier for cases that document patient safety concerns for discontinuing the procedure.

The catch: Some payers may require modifier 53 for an incomplete ERCP. The only way to know for sure is to check with your payer before choosing between the code pair.  

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